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Study finds second intravitreal injection of triamcinolone has additional benefit against AMD
Most increases in IOP subsided after 6 months or were controlled using medications. No eyes required cataract surgery during follow-up.
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NUREMBERG, Germany — A second injection of triamcinolone acetonide can have a beneficial effect against exudative age-related macular degeneration in eyes that responded to an initial intravitreal injection, according to a study presented here.
Ingrid Kreissig, MD, and colleagues of the faculty of clinical medicine of Mannheim at the University of Heidelberg studied the effect of a second injection of 20 mg triamcinolone acetonide in 13 patients with exudative AMD. These patients were compared to a control group of 24 patients who received only observation.
Dr. Kreissig told Ocular Surgery News in an interview that patients in the study group experienced an improvement in visual acuity after both injections.
She said more than two injections seem to be possible but also noted that she was hesitant to say whether injections could be repeated indefinitely. A larger series of eyes with longer follow-up is needed, she said.
She noted re-injections are only appropriate in those eyes that did not experience serious adverse events after the first injection. For example, she said if no ocular hypertension was experienced after the first injection, it should not be expected after subsequent injections. Conversely, if an increase in IOP was seen after the first injection, it should be expected after a second injection.
Dr. Kreissig presented the results of the study at the German Ophthalmic Surgeons annual meeting.
Sterile injections
According to Dr. Kreissig, patients in both groups were similar in age, ranging from 78 to 79 years, and both groups had a mean baseline VA of 0.17. All eyes showed subfoveal choroidal neovascularization on fluorescein angiography.
Only patients in the study group received intravitreal injections containing 20 mg triamcinolone acetonide. She noted all injections were prepared under sterile conditions and done in an operating room with the patient prepared and draped as for intraocular surgery, and all study patients received antibiotic eye drops after the injections. All of these precautions are necessary to avoid endophthalmitis, she said.
After the first injection, patients had a mean follow-up of 7.2 months (range 3.1 to 18 months) before receiving the second intravitreal injection. Mean follow-up after the second injection was 5.3 months, Dr. Kreissig said.
Stabilization of vision
| Multiple re-injections | |
| Although Ingrid Kreissig, MD, said more than two to three injections of triamcinolone acetonide seem possible, she said she was hesitant to say whether injections can be repeated indefinitely. Larger series of eyes with longer follow-up are needed. Dr. Kreissig said that she and colleagues in Mannheim have one patient with exudative age-related macular degeneration who has received six injections of 20 mg triamcinolone acetonide in one eye, with an increase in visual acuity noted after each injection. Three re-injections were done after 6 months follow-up, one after 5 months and one after 10 months, she said. The patient has not experienced secondary ocular hypertension or endophthalmitis but did require cataract surgery after the fourth injection, she said. |
According to Dr. Kreissig, all patients in the study group had experienced an increase or stabilization in VA after the first triamcinolone injection.
She said a statistically significant improvement in VA was seen 2 months after the first triamcinolone injection, with mean VA improving from 0.17 ± 0.11 to a maximum of 0.32 ± 0.26.
VA improved in 10 of the 13 eyes (77%) and remained unchanged in the remaining three eyes. Dr. Kreissig noted that six eyes (46%) also showed an improvement in VA of more than two Snellen lines.
After the second triamcinolone injection, mean VA in the study group again significantly improved, from 0.15 ± 0.14 to a maximum of 0.23 ± 0.19. Six eyes (46%) experienced a repeated improvement in VA of more than two Snellen lines.
Visual acuity in the control group did not significantly change during the follow-up period, Dr. Kreissig said. She noted that at the end of the study VA was significantly different between the study and control groups.
No eyes required cataract surgery.
Some IOP increases
According to Dr. Kreissig, the study group experienced a significant increase in mean IOP after both triamcinolone injections. However, there was no significant difference in the increase in IOP after either injection.
The increases in IOP usually subsided after 6 months, she said.
After the first injection, mean IOP increased from 14.7 mm Hg to a maximum of 20.2 mm Hg during follow-up. Four eyes had an increase in IOP above 21 mm Hg but were controlled using antiglaucoma medications, she said.
“Now if you analyze all the study eyes, the maximum IOP after the second injection was quite surprisingly lower,” she said.
After the second injection, mean IOP increased from 16.1 mm Hg to a maximum of 19 mm Hg, with the highest IOP recorded between 3 and 5 months after re-injection. Three eyes (23%) had an IOP above 21 mm Hg — two needed antiglaucoma drops, and one required a trabeculectomy for IOP control.
Dr. Kreissig noted the two eyes that required additional IOP control after the second injection already had increased IOP after the first injection.
For Your Information:
- Ingrid Kreissig, MD, is an adjunct professor of clinical ophthalmology, New York Hospital - Cornell Medical Center, United States, and a professor of ophthalmology, faculty of clinical medicine, Mannheim, Germany. She can be reached at Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; 49-621-383-25-97; fax: 49-621-383-3803; e-mail: Ingrid.kreissig@augen.ma.uni-heidelberg.de; Web site: http://kreissig.uni-hd.de.
- OSN Staff Writer Michael Piechocki covers ophthalmology in Europe, Asia and the Pacific region. He also specializes in oculoplastics.